The SARS-CoV-2 virus is similar to MERS-CoV and SARS-CoV which originated in bats. It is believed this virus emerged from exposure to a seafood and live animal marker in Wuhan, China but it is now known that this disease is spread from person-person. (1) Since bats were hibernating during the outbreak, it is unlikely they infected humans directly and therefore needed an intermediate host. In a recent paper, researchers were able to isolate the 2019 novel Coronavirus (2019-nCoV) strain in Malayan pangolins. (2) The findings in the paper suggests that the 2019-nCoV originated from the recombination of a Pangolin CoV like virus with Bat CoV like virus. (2) Antibodies from infected pangolins reacted with the S protein of 2019-nCoV which also strengthened the hypothesis that these animals were an intermediate host for the novel virus. The paper also mentioned how pangolin CoV binds to human angiotensin converting enzyme 2 (ACE2) which makes it a huge threat to public health. (2) Pangolins are illegally traded in Southeast Asia with their meat used as a delicacy and their scales used in medicine in China. (2) The authors in the paper write how there should be better regulation of the illegal trade of pangolins to prevent major outbreaks of other coronavirus like viruses. (2). 

Surveillance of 2019-nCoV

According to the World Health Organization (WHO), the goal of surveillance of the 2019-nCoV is to monitor trends of the disease, detect new cases in countries where the virus is not circulating and to provide epidemiological information to conduct risk assessment and guide response measures. (3) According to WHO, national authorities are required to report probable and confirmed cases of 2019-nCoV within 24 hours of identification. Probable cases are defined as a case whose testing is inconclusive or pan-coronoavirus positive without evidence of other respiratory pathogens. A confirmed case is a person with laboratory confirmation of 2019-nCoV regardless of the clinical picture. (3) In countries with high numbers of importation or person-to-person transmission they are required to report weekly to WHO with the total number of cases and deaths since onset of outbreak, number of reported cases, deaths, hospitalized and severe cases by age group and sex, number of laboratory tests conducted and the number positive for 2019-nCoV and number of contacts under follow up or new identified contacts. (3) 

 

 

1.       https://www.cdc.gov/coronavirus/2019-ncov/summary.html

2.       Xiao, K., Zhai, J., et al. Isolation and Characterization of 2019-nCoV-like Coronavirus from Malayan Pangolins. bioRxiv. 2020.02.17.951335; doi: https://doi.org/10.1101/2020.02.17.951335

3.       https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)

Health care workers in Wuhan have been fighting endlessly to help combat Covid19, treating patients that have been diagnosed while also trying to remain virus-free themselves; unfortunately, a lack of resources has proven to be one of their biggest hurdles (1). Dire shortages of PPE and necessary medical equipment have led Wuhan doctors to reuse one-time goggles, patch used protective masks with tape and wrap their shoes in plastic bags as they no longer have access to specialized coverings (1). It has been reported that some health care professionals have purchased protective gear with their own money, begged friends or relied on donations while others have avoided eating/drinking/using the restroom for extended periods of time to avoid discarding and replacing their PPE (1). 

While Physicians in China are not required to take the Hippocratic Oath, many of them are still battling at the forefront of this epidemic, risking their health to help the citizens of Wuhan (2,1). However, a lot of the efforts made by health care professionals to control the spread of Covid19 are negated by the Chinese government and officials. Doctors and hospital workers have been under enormous pressure to not speak out about the outbreak, keeping key details secret as to not scare the general public (1). Dr. Li Wenliang is a prime example of the censorship physicians are under by Chinese officials. In December of 2019, Dr. Li attempted to warn his colleagues out the outbreak only to be visited by police and told to stop or he will be brought to justice; Dr. Li contracted Covid19 just one week after his interaction with the police and ended up dying as a result of the infection (3). Ten days after Dr. Li's diagnosis, China declared the outbreak an emergency (3).  Cai Yi, head of the division of pain management at Wuhan Central Hospital was quoted as saying " Of course I'm nervous about getting infected...but if we let ourselves be nervous, then what would happen to the people?" (1). Cai Yi's statement speaks volumes about the attitude of Chinese health care workers as they are risking their careers and lives to help others. 

Comparatively, hospitals and physicians in the US are doing everything they can to prepare for the potential explosion of Covid19 in the states (4). Dr. Nathan Hatton, a pulmonologist at University of Utah Heath mentioned that they are currently going through their current protocols to ensure they are compatible with Covid19 (4). Hospitals across the country are scheduling almost daily meetings to double and triple check their emergency preparedness plans and ensure they have staff that are properly trained and an abundance of resources on hand (4). Also contrary to the Wuhan response, doctors in the US have been openly addressing the fears and concerns of their patients, setting up response lines with educated, trained employees that are capable of reassuring patients while providing them with factual information (4). 

What, if anything, can be done to help combat resource strain observed in Wuhan? Do you agree with the restrictions set by Chinese officials to limit the amount of information doctors and physicians can share about Covid19? 

1. Buckley, C., Lee Wee, S., Qin, A., (2020), China's doctors, fighting the coronavirus, beg for masks, New York Times,  https://www.nytimes.com/2020/02/14/world/asia/china-coronavirus-doctors.html

2. China Briefing, (2008), The hippocratic oath, china medical insurance and beijing olympics medical care, China Briefing,  https://www.china-briefing.com/news/the-hippocratic-oath-china-medical-insurance-and-beijing-olympics-medical-care/

3. Hegarty, S., (2020), The chinese doctor who tried to warn others about coronavirus, BBC News,  https://www.bbc.com/news/world-asia-china-51364382

4. Thielking, M., (2020), We need everyone for this: US hospitals harnessing resources to brace for any spike in coronavirus cases, STAT News,  https://www.statnews.com/2020/02/07/hospitals-harnessing-resources-brace-spike-coronavirus-cases/

Initially, an increased number of pneumonia cases had been seen in Wuhan City in December 2019. After performing genetic sequencing, these patients were diagnosed with 2019-nCoV. Not all of the infected had traveled recently. However, many had come into close contact with those being monitored for infection (2).

The exact source of this virus is not fully known. What is known, is that most cases are due to human-human transmission. The 2019-nCoV is suggested to have a broad host range with wild animals as its origin. Many individuals infected with the virus had recently visited a large seafood and animal market in Wuhan, which also suggests the wild animal origin. Genetic sequencing has shown that the new virus is similar to strains that have originated from wild animals in the past and that 2019 n-CoV may have emerged particularly from a virus related to coronaviruses transmitted by bats. Bats harbor viruses that are genetically similar to the 2019-nCoV, which makes them the possible source of infection. There are other wild animals in the animal markets in China that also harbor related coronaviruses and may serve as intermediate hosts which help spread the virus to humans (3).

Although the exact emergence factors of this novel coronavirus is still not fully known, you can look at past outbreaks to get an idea about possible sources. Both SARS-CoV and MERS-CoV were transmitted to humans from market civets (wild cats), with origins in bats. SARS-CoV emerged through recombination of bat SARS-related coronaviruses. When researchers were studying the SARS epidemic, SARS-CoV and anti-SARS-CoV antibodies were identified in palm civets. With this information, researchers were able to find that the SARS-CoV strains found in these market civets were passed to them by other animals.(4).  

1. Cohut, Maria. (Feb 7, 2020). Novel coronaviruus: Your questions, answered. Retrieved from https://www.medicalnewstoday.com/articles/novel-coronavirus-your-questions-answered#8.-How-is-the-virus-treated?

2. Bajema KL, Oster AM, McGovern OL, et al. Persons Evaluated for 2019 Novel Coronavirus — United States, January 2020. MMWR Morb Mortal Wkly Rep 2020;69:166–170. DOI: http://dx.doi.org/10.15585/mmwr.mm6906e1


3. Information on the Emergence and Transmission of 2019 Novel Coronavirus (2019-nCoV). (n.d.). Retrieved February 19, 2020, from https://globalonehealth.osu.edu/about-us/news/information-emergence-and-transmission-2019-novel-coronavirus-2019-ncov\

4. Cui, J., Li, F. & Shi, Z. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol 17, 181–192 (2019). https://doi.org/10.1038/s41579-018-0118-9

The Chinese government has attempted to contain COVID-19 by imposing a mass quarantine on Wuhan, where the disease first started, and 15 additional cities in Hubei Province, affecting around 57 million people total (1). The government also suspended travel by air and railroad around Wuhan (2).  

The economic impact will most likely be great to China; there is an estimate similar to the SARS outbreak (1).  However, it will be interesting to see how COVID-19 impacts the economy due to the different factors such as mass quarantine in general, air and rail suspension, and larger economy than in 2003. 

Nothing goes without debate, however.  It has been said that Wuhan officials and others higher in the province were slower to react to the outbreak until Xi Jinping, who is the General Secretary of the Communist Party of China, commented that the peoples’ health and safety were at stake and that something must be done (1). Even in mid-January, there were National Health Commission public health officials who were calling COVID-19 (still then unnamed) “preventable and controllable) (1). There are plenty of theories out there on what the government knew, didn't know, and did/did not respond to properly to weed through.

Thankfully, the government did utilize resources to build a medical facility in order to be able to treat COVID-19 patients in Wuhan, which was set to be completed February 3; however, a second hospital will be built with 1300 beds to be done in only half a month (3).  

As of February 4, 2020, a division of the Republic of Korea’s (ROK) government placed restrictions on entry to the ROK, or South Korea for the following: anyone with passports or visas issued in Hubei Province (where Wuhan is located), China; all foreign nationals who visited Hubei Province, China in the last 14 days; visa-free entry to Chinese nationals and foreign nationals traveling from China (4) The same website issued a notice on January 28, 2020 called “Notice on the Prevention of Infection with a Novel Coronavirus” and discusses symptoms, protection, and what to do if exhibiting symptoms. The Korea Center for Disease Control just confirmed 204 positive cases of COVID-19, a great increase of cases just over this past weekend and pointing overall to cases from the city of Daegu (SE of Seoul).  Because of this, authorities are reporting community-based transmission is now occurring (5).  

Hong Kong’s government put a mandatory 14-day quarantine in place for anyone arriving in Hong Kong who has come from visiting China in the past 14 days (2).  People are receiving screenings at the borders, and transportation and ferry service with China have been suspended (2).

The Department of State’s original travel advisory for China was a Level 3 (reconsider travel), but was updated to a Level 4 (do not travel) on January 30, 2020 (2).  If citizens absolutely must travel, there are strict procedures in place, including up to 14 days of quarantine if coming back from Hubei province, possible self-quarantine/health screening if returning from the rest of China, monitoring media, and other supplemental instructions (2). In addition, the US Dept. of State called for all family members of US personnel under the age of 21 to leave China as of January 31, 2020. 

There was also an official proclamation signed by President Trump refusing entry to most foreign nationals and others who have been to China in the past 14 days (as written: "immigrant or nonimmigrant"); this took effect on February 2, 2020, and is available in its entirety here: 

https://www.whitehouse.gov/presidential-actions/proclamation-suspension-entry-immigrants-nonimmigrants-persons-pose-risk-transmitting-2019-novel-coronavirus/

The Dept. of State strongly advises US citizens not to vacation on cruise ships to Asia, as multiple countries have enforced screenings, quarantines, or even bans. You may even recall the story regarding the Diamond Princess ship that was quarantined, and now several of those passengers have even unfortunately passed away (6).    

I do think one has to be careful when researching anything about COVID-19 no matter what the subject matter, and government action is no different.  Has anyone encountered any news reports where they read something extreme about the response of a particular country’s government to COVID-19 that actually turned out to be exaggerated??  Has anyone heard of any other countries with a demonstrated response to COVID-19?

1. CSIS-Center for Strategic & International Studies. (2020). The novel coronavirus outbreak. https://www.csis.org/analysis/novel-coronavirus-outbreak

2. Travel.State.Gov. (2020). Current outbreak of coronavirus disease 2019. https://travel.state.gov/content/travel/en/traveladvisories/ea/novel-coronavirus-hubei-province--china.html

3. Reuters. (2020). China’s Wuhan to build second designated hospital to treat coronavirus patients. https://www.reuters.com/article/us-china-health-hospital/chinas-wuhan-to-build-second-designated-hospital-to-treat-coronavirus-patients-state-media-idUSKBN1ZO0C4

4. Ministry of Justice, Korean Immigration Services. (2020). Coronavirus entry restrictions. http://immigration.go.kr/immigration_eng/index.do

5. US Embassy & Consulate in the Republic of Korea. (2020). Health Alert: Increase of COVID-19 cases in the ROK. https://kr.usembassy.gov/022120-health-alert-increase-of-covid-19-cases-in-the-republic-of-korea-rok/

6. USA Today. (2020). Third Diamond Princess passenger, 80-year-old Japanese man, dies after coronavirus quarantine. https://www.usatoday.com/story/travel/cruises/2020/02/23/coronavirus-quarantine-diamond-princess-third-passenger-dies/4849616002/

Cases of the 2019 nCoV have exponentially grown as weeks have gone on. One of the efforts in preventing further transmission of the virus has been to focus on containment strategies. The CDC produced guidelines for public health entities. These guidelines state that persons who recently travelled from the Hubei province of China are currently at high risk, whether they are symptomatic or not (1). It’s recommended that patients without symptoms be quarantined, while those with symptoms are to be isolated and treated (1). In addition, air travel has been restricted in and out of China for U.S as a level 3 guidance to avoid nonessential travel (2). Travel to Japan and South Korea have also been discouraged, including cruise ships in Asia (2). Our society typically depends on air travel and this type of travel is one of the easiest ways to spread an infectious disease from continent to continent. 

One strategy being used is social distancing, which closes public facilities where a large number of people could gather in order to limit person to person transmission, as we know can occur (3). However, even with containment strategies, such as isolation, quarantine, air travel restrictions, and social distancing, China has seemingly been unable to reach the level of containment that is needed (3), according to Dr. Robert Redfield of the CDC. Wuhan, China where the virus originated, has been on a quarantined lockdown with travel restricted (4). China’s lockdown included upwards of 46 million people, as many public facilities and services were shut down (5). However, this lockdown also has led to difficulty accessing food and various supplies (5). 

1. Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposure in Travel-associated or Community Settings. (2020). Retrieved 24 February 2020, from https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html

2.COVID-19 Situation Summary. (2020). Retrieved 24 February 2020, from
 https://www.cdc.gov/coronavirus/2019-ncov/summary.html

3. Branswell, H. (2020). CDC director: More person-to-person coronavirus infections in U.S. likely. Retrieved 26 February 2020, from
 https://www.statnews.com/2020/02/12/cdc-director-more-person-to-person-coronavirus-infections-in-u-s-likely-but-containment-still-possible/

4. Begley, S. (2020). Wuhan quarantine bought the world time to prepare for Covid-19 - STAT. Retrieved 24 February 2020, from
 https://www.statnews.com/2020/02/21/coronavirus-wuhan-quarantine-bought-world-time-to-prepare/

5. Colarossi, N. (2020). China put 46 million people on lockdown to contain the Wuhan coronavirus, and now the US is prepared to quarantine people, too. But quarantines throughout history have been riddled with mishaps. Retrieved 26 February 2020, from https://www.businessinsider.com/quarantine-history-following-china-wuhan-coronavirus-lockdowns-2020-1#the-trump-administration-is-taking-precautionary-measures-to-prevent-the-virus-form-spreading-in-the-us-16